-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
October 01, 2015 - Year
PSI 02 Death Rate in Low-Mortality Diagnosis-
Related Groups (DRGs)
0.32 0347 2012
PSI 03 Pressure … Thrombosis Rate
4.99 0450 2012
PSI 13 Postoperative Sepsis Rate 9.61
PSI 14 Postoperative Wound … Laceration Rate X 1.89 0345 2012
PSI 16 Transfusion Reaction Count X N/A* 0349 2012
PSI 17 Birth Trauma … Rate – Injury to Neonate 1.89
PSI 18 Obstetric Trauma Rate – vaginal delivery
with instrument … 133.19
PSI 19 Obstetric Trauma Rate – vaginal delivery
without instrument
20.97
PSI 90
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/tools-resources.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/contactsheet.html
March 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6ref.html
July 01, 2018 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/organization-readiness.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/hazard-report-form.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/best-practices.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/manage-change-checklist.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/contactsheet2.html
March 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/implementation-guide/index.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
March 01, 2004 - observed, “Medicare is spending billions to treat preventable (fall) injuries…at an
average cost of … Medicare could realize substantial savings if these injuries could be
prevented.”15 Prevention of pressure … billion.17
Falls and pressure ulcers are often avoidable. … average cost of $1,272 per injury14 and assuming conservatively that
one out of ten falls results in injury … Preventing Falls and Pressure Ulcers
85
12. Dyck MJ.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
March 01, 2016 - Rate 0 0 - 0.0006572
PDI1 PDI #1 Accidental Puncture or Laceration Rate 0 0 - 0.00053522
PDI2 PDI #2 Pressure … Count 0 - - -
PSI2 PSI #2 Death Rate in Low-Mortality DRGs 8 132 0.06060606 0.00028197
PSI3 PSI #3 Pressure … Rate – Injury to Neonate 0 0 - 0.00210694
PSI18 PSI #18 Obstetric Trauma Rate – Vaginal Delivery With … Diagnosis Related Groups (DRGs)
8 132 0.060606 0.001046 57.95983 0.000282 0.016343 0.007641
PSI #3 Pressure … Rate - Injury
to Neonate
0.002107
PSI #18 Obstetric Trauma Rate -
Vaginal Delivery With
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt6.html
December 01, 2017 - Patient Safety
Patient Safety Resources by Setting
Long Term Care
Resources
Injuries … Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … ( ) Postural hypotension
≥20 mm Hg drop in systolic pressure with position change … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt6.html
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4e_combo_psi08-postophipfx-bestpractices.pdf
May 20, 2016 - In 2008 the Centers for
Medicaid & Medicare Services (CMS) identified falls and trauma—including fractures—as … Prevention
Protocol
Use a standardized fall prevention protocol to help reduce falls
and associated injury … /fallspx/fallspxmanual.pdf
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Transforming care at the bedside how-to guide: reducing patient injuries from
falls.http://www.ihi.org … High blood pressure and bone-mineral loss in elderly white women: a prospective
study.
-
ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - 2
In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/algorithm.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Exclusion criteria: unstable vital signs, orthostatic by blood pressure or pulse criteria, specific
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/jones2-report.pdf
January 01, 2024 - ,3
with an average associated excess cost of $7,000 per injury.4 Regardless of injury, falling can lead … .35
Consequently, randomized controlled trials of individual processes, such as use of bed/chair pressure … Supervisor/Manager Expectations & Actions Promoting Patient
Safety (α = .92)
83 80 .88
Whenever pressure … REFINE (REducing Falls in In-patieNt Elderly) using bed and
bedside chair pressure sensors linked to … Circumstances of patient falls and injuries in 9 hospitals in a
Midwestern healthcare system.
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/guide3.html
February 01, 2016 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … associated with a very high risk of VTE include abdominal or pelvic surgery for cancer, multiple major trauma … Examples include craniotomy, traumatic brain injury, spinal cord injury repair, major trauma, plastic … use, ideally used for 18 hours or more. 4
Prophylaxis for Knee Arthroscopy and Isolated Lower Leg Injuries … The same recommendation applies to patients with isolated lower leg injuries distal to the knee that
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-5.html
July 01, 2022 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … for each of the patient's current medications documented (i.e., documenting plan to continue blood pressure
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2d.docx
January 28, 2013 - Monthly falls analysis by:
location and time of fall
shift and day of week
type of injury … consequences of falls
High-risk medications, sleep hygiene measures for management of anxiety
Low blood pressure